Skip to main content

Pitfalls in the Acute Management of Atrial Fibrillation

  • Chapter
  • First Online:
  • 977 Accesses

Part of the book series: Contemporary Cardiology ((CONCARD))

Abstract

The evaluation and management of atrial fibrillation is complex, and errors can lead to patient harm. Pitfalls to avoid are numerous—incorrect diagnosis can lead to improper treatment or omission of appropriate therapies, inappropriate management of anticoagulation in atrial fibrillation (AF) places the patient at risk of debilitating stroke or bleeding complications, and injudicious use of antiarrhythmic drug (AAD) therapy can risk dangerous pro-arrhythmic side effects. Furthermore, direct current cardioversion carries its own unique procedural risks. The astute clinician will be aware of potential mistakes and, by avoiding them, will deliver safe and optimal patient care. This chapter will highlight potential errors in AF care.

This is a preview of subscription content, log in via an institution.

Buying options

Chapter
USD   29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD   84.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD   119.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD   109.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Learn about institutional subscriptions

References

  1. The AFFIRM Investigators. Survival of patients presenting with atrial fibrillation in the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) study. N Engl J Med. 2002;347:825–33.

    Google Scholar 

  2. Van Gelder IC, Groenveld HF, Crijns HH, et al. Lenient versus strict rate control in patients with atrial fibrillation. N Engl J Med. 2010;362:1363–73.

    Article  PubMed  Google Scholar 

  3. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. Circulation. 2014;130:e199–267.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Vamos M, Erath JW, Hohnloser SH. Digoxin-associated mortality: a systematic review and meta-analysis of the literature. Eur Heart J. 2015;36:1831–8.

    Article  PubMed  Google Scholar 

  5. Rathore SSS, Curtis JP, Wang Y, et al. Association of serum digoxin concentration and outcomes in patients with heart failure. JAMA. 2003;289:871–8.

    Article  CAS  PubMed  Google Scholar 

  6. Whitbeck MG, Charnigo RJ, Khaled P, et al. Increased mortality among patients taking digoxin- analysis from the AFFIRM study. Eur Heart J. 2013;34:1481–8.

    Article  CAS  PubMed  Google Scholar 

  7. The Digitalis Investigation Group. The effect of digoxin on mortality and morbidity in patients with heart failure. N Engl J Med. 1997;336:525–33.

    Article  Google Scholar 

  8. Glotzer TV, Daoud EG, Wyse DG, et al. The relationship between daily atrial tachyarrhythmia burden from implantable device diagnostics and stroke risk: the TRENDS study. Circ Arrhythm Electrophysiol. 2009;2:474–80.

    Article  PubMed  Google Scholar 

  9. Glotzer TV, Hellkamp AS, Zimmerman J, et al. Atrial high rate episodes detected by pacemaker diagnostics predict death and stroke: report of the Atrial Diagnostics Ancillary Study of the MOde Selection Trial (MOST). Circulation. 2003;107:1614–9.

    Article  PubMed  Google Scholar 

  10. Ziegler PD, Glotzer TV, Daoud EG, et al. Incidence of newly detected atrial arrhythmias via implantable devices in patients with a history of thromboembolic events. Stroke. 2010;41:256–60.

    Article  PubMed  Google Scholar 

  11. Ziegler PD, Glotzer TV, Daoud EG, et al. Detection of previously undiagnosed atrial fibrillation in patients with stroke risk factors and usefulness of continuous monitoring in primary stroke prevention. Am J Cardiol. 2012;110:1309–14.

    Article  PubMed  Google Scholar 

  12. Wolf PA, Mitchell JB, Baker CS, et al. Impact of atrial fibrillation on mortality, stroke, and medical costs. Arch Intern Med. 1998;158:229–34.

    Article  CAS  PubMed  Google Scholar 

  13. Lin HJ, Wolf PA, Kelly-Hayes M, et al. Stroke severity in atrial fibrillation. The Framingham study. Stroke. 1996;27:1760–4.

    Article  CAS  PubMed  Google Scholar 

  14. McGrath ER, Kapral MK, Fang J, et al. Association of atrial fibrillation with mortality and disability after ischemic stroke. Neurology. 2013;81(9):825–32.

    Article  PubMed  Google Scholar 

  15. Sandercock P, Bamford J, Dennis M, et al. Atrial fibrillation and stroke: prevalence in different types of stroke and influence on early and long term prognosis (Oxfordshire community stroke project). BMJ. 1992;305:1460–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Marini C, De Santis F, Sacco S, et al. Contribution of atrial fibrillation to incidence and outcome of ischemic stroke: results from a population-based study. Stroke. 2005;36:1115–9.

    Article  PubMed  Google Scholar 

  17. Nasraway SA. Avoiding pitfalls of anticoagulation therapy. J Healthc Risk Manag. 2007;27(2):35–9.

    Article  PubMed  Google Scholar 

  18. McCormick WP. Medical-legal implications of anticoagulation. J Thromb Thrombolysis. 2001;12(1):95–7.

    Article  CAS  PubMed  Google Scholar 

  19. Klein AL, Grimm RA, Murray RD, et al. Use of transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation. N Engl J Med. 2001;344:1411–20.

    Article  CAS  PubMed  Google Scholar 

  20. Khan IA. Atrial stunning: determinants and cellular mechanisms. Am Heart J. 2003;145(5):787–94.

    Article  CAS  PubMed  Google Scholar 

  21. Camm AJ, Lip GY, De Canterina R, et al. 2012 focused update of the ESC guidelines for the management of atrial fibrillation: an update of the 2010 ESC guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J. 2012;33:2719–47.

    Article  PubMed  Google Scholar 

  22. Lip GY, Nieuwlaat R, Pisters R, et al. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation. Chest. 2010;137:263–72.

    Article  PubMed  Google Scholar 

  23. Olesen JB, Torp-Pedersen C, Hansen ML, et al. The value of the CHA2DS2-VASc score for refining stroke risk stratification in patients with atrial fibrillation with a CHADS2 score of 0–1: a nationwide cohort study. Thromb Haemost. 2012;107:1172–9.

    Article  CAS  PubMed  Google Scholar 

  24. Mason PK, Lake DE, DiMarco JP, et al. Impact of the CHA2DS2-VASc score on anticoagulation recommendations for atrial fibrillation. Am J Med. 2012;125:603–6.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Hart RG, Pearce LA, Rothbart RM, et al. Stroke with intermittent atrial fibrillation: incidence and predictors during aspirin therapy. J Am Coll Cardiol. 2000;35(1):183–7.

    Article  CAS  PubMed  Google Scholar 

  26. Pisters R, Lane DA, Nieuwlaat R, et al. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the euro heart survey. Chest. 2010;138:1093–100.

    Article  PubMed  Google Scholar 

  27. Wang TJ, Massaro JM, Levy D, et al. A risk score for predicting stroke or death in individuals with new-onset atrial fibrillation in the community: the Framingham heart study. JAMA. 2003;290(8):1049–56.

    Article  PubMed  Google Scholar 

  28. Mant J, Hobbs FD, Fletcher K, et al.; BAFTA investigators, Midland Research Practices Network (MidReC). Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomized control trial. Lancet. 2007;370(9586):493–503.

    Google Scholar 

  29. Gallagher AM, Rietbrock S, Plumb J, et al. Initiation and persistence of warfarin or aspirin in patients with chronic atrial fibrillation in general practice: do the appropriate patients receive stroke prophylaxis? J Thromb Haemost. 2008;6:1500–6.

    Article  CAS  PubMed  Google Scholar 

  30. Banerjee A, Clementy N, Haguenoer K, et al. Prior history of falls and risk of outcomes in atrial fibrillation: the Loire Valley atrial fibrillation project. Am J Med. 2014;127(10):972–8.

    Article  PubMed  Google Scholar 

  31. Gage BF, Birman-Deych E, Kerzner R, et al. Incidence of intracranial hemorrhage in patients with atrial fibrillation who are prone to fall. Am J Med. 2005;118(6):612–7.

    Article  PubMed  Google Scholar 

  32. Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med. 2007;146:857–67.

    Article  PubMed  Google Scholar 

  33. Wan Y, Heneghan C, Perera R, et al. Anticoagulation control and prediction of adverse events in patients with atrial fibrillation: a systematic review. Circ Cardiovasc Qual Outcomes. 2008;1(2):84–91.

    Article  PubMed  Google Scholar 

  34. Dlott JS, George RA, Huang X, et al. National assessment of warfarin anticoagulation therapy for stroke prevention in atrial fibrillation. Circulation. 2014;129(13):1407–14.

    Article  CAS  PubMed  Google Scholar 

  35. Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009;361:1139–51.

    Article  CAS  PubMed  Google Scholar 

  36. Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011;365:883–91.

    Article  CAS  PubMed  Google Scholar 

  37. Granger CB, Alexander JH, McMurray JJ, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011;365:981–92.

    Article  CAS  PubMed  Google Scholar 

  38. Giugliano RP, Ruff CT, Braunwald E, et al. Edoxaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2013;369:2093–104.

    Article  CAS  PubMed  Google Scholar 

  39. Holmes DR, Kar S, Price MJ, et al. Prospective randomized evaluation of the watchman left atrial appendage closure device in patients with atrial fibrillation versus long-term warfarin therapy. J Am Coll Cardiol. 2014;64(1):1–12.

    Article  PubMed  Google Scholar 

  40. Katz ES, Tsiamtsiouris T, Applebaum RM, et al. Surgical left atrial appendage ligation is frequently incomplete: a transesophageal echocardiographic study. J Am Coll Cardiol. 2000;36(2):468–71.

    Article  CAS  PubMed  Google Scholar 

  41. Aberg H. Atrial fibrillation: I. A study of atrial thrombosis and systemic embolism in a necropsy material. Acta Med Scand. 1969;185:373–9.

    Article  CAS  PubMed  Google Scholar 

  42. Wu N, Tong S, Xiang Y, et al. Association of hemostatic markers with atrial fibrillation: a meta-analysis and meta-regression. PLoS One. 2015;10:e0124716. doi:10.1371/journal.pone.0124716.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Echt DS, Liebson PR, Mitchell LB, et al. Mortality and morbidity in patients receiving encainide, flecainide, or placebo: the Cardiac Arrhythmia Suppression Trial (CAST). N Engl J Med. 1991;324(12):781–8.

    Article  CAS  PubMed  Google Scholar 

  44. Myerburg RJ, Castellanos A. Electrode positioning for cardioversion of atrial fibrillation. Lancet. 2002;360:1263.

    Article  PubMed  Google Scholar 

  45. Kirchhof P, Eckardt L, Loh P, et al. Anterior-posterior versus anterior-lateral electrode positions for external cardioversion of atrial fibrillation: a randomized trial. Lancet. 2002;360:1275.

    Article  PubMed  Google Scholar 

  46. Botto GL, Politi A, Bonini W, et al. External cardioversion of atrial fibrillation: role of paddle position on technical efficacy and energy requirements. Heart. 1999;82:726.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  47. Efremidis M, Sideris A, Batra R, et al. Facilitating internal cardioversion of chronic atrial fibrillation with ibutilide—predictors of atrial defibrillation-threshold decrease. Med Sci Monit. 2004;10(6):CR258–63.

    PubMed  Google Scholar 

  48. Bieganowska K, Rekawek J, Szumowski T, et al. Morgagni-Adams-Stokes after adenosine injection in a patient with WPW syndrome- a case report. Kardiol Pol. 2006;64:1453–7.

    PubMed  Google Scholar 

  49. Boriani G, Biffi M, Frabetti L, et al. Ventricular fibrillation after intravenous amiodarone in Wolff-Parkinson-White syndrome with atrial fibrillation. Am Heart J. 1996;131(6):1214–6.

    Article  CAS  PubMed  Google Scholar 

  50. Simonian SM, Lotfipour S, Wall C, et al. Challenging the superiority of amiodarone for rate control in Wolff-Parkinson-White and atrial fibrillation. Intern Emerg Med. 2010;5:421–6.

    Article  PubMed  Google Scholar 

  51. Kim RJ, Gerling BR, Kono AT, et al. Precipitation of ventricular fibrillation by intravenous diltiazem and metoprolol in a young patient with occult Wolff-Parkinson-White syndrome. Pacing Clin Electrophysiol. 2008;31:776–9.

    Article  CAS  PubMed  Google Scholar 

  52. Ebrahimi R, Rubin SA. Electrical cardioversion resulting in death from synchronization failure. Am J Cardiol. 1994;74(1):100–2.

    Article  CAS  PubMed  Google Scholar 

  53. Li-Saw-Hee FL, Lip GY. Digoxin revisited. QJM. 1998;91:259–64.

    Article  CAS  PubMed  Google Scholar 

  54. Ma G, Brady WJ, Pollack M, et al. Electrocardiographic manifestations: digitalis toxicity. J Emerg Med. 2001;20(2):145–52.

    Article  CAS  PubMed  Google Scholar 

  55. Bismuth C, Gaultier M, Conso F, et al. Hyperkalemia in acute digitalis poisoning: prognostic significance and therapeutic implications. Clin Toxicol. 1973;6(2):153–62.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to David E. Winchester MD, MS, FACP, FACC .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2016 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Winchester, D.E., Kaufmann, M.R., McKillop, M.S., Miles, W.M. (2016). Pitfalls in the Acute Management of Atrial Fibrillation. In: Peacock, W., Clark, C. (eds) Short Stay Management of Atrial Fibrillation. Contemporary Cardiology. Humana Press, Cham. https://doi.org/10.1007/978-3-319-31386-3_14

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-31386-3_14

  • Published:

  • Publisher Name: Humana Press, Cham

  • Print ISBN: 978-3-319-31384-9

  • Online ISBN: 978-3-319-31386-3

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics